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Rates of Fertility Preservation Use Among Transgender Adolescents

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Rates of Fertility Preservation Use Among Transgender Adolescents Letters RESEARCH LETTER Figure. Reasons for Declining Fertility Preservation Rates of Fertility Preservation Use Among Transgender Adolescents 100 Transgender adolescents are increasingly seeking hormonal in- Did not wish to provide a masturbatory sample tervention to achieve a body consistent with their gender 80 Experimental nature of procedure identity. These treatments include gonadotropin-releasing hor- Would rather surrogacy, in vitro fertilization, or another intervention mone agonists (GnRHa) to suppress puberty and the gender- Invasiveness of procedure 60 affirming hormones testosterone and estrogen. Given that Costs associated with procedure these interventions affect reproductive function, current treat- Not wishing to delay treatment Will consider intervention in future ment guidelines recommend prior fertility counseling and ac- 40 Responses, % Responses, cess to fertility preservation (FP).1 However, despite a previ- Did not want biological children and/or would rather adopt ous report that 36% of transgender adolescents want biological or foster children children in the future,2 3 recent North American studies3-5 iden- 20 Did not want children Did not wish to be pregnant tified that less than 5% of transgender adolescents accessed FP. Whether these low rates reflect service barriers (eg, cost 0 and availability), unwillingness to delay hormonal treatment AFAB AMAB for FP, and/or an intrinsic lack of desire for FP is unclear. To understand why some patients chose not to pursue fertility preservation, We performed a retrospective review to examine FP use we examined reasons recorded in the medical record. Of the 49 young people among transgender adolescents receiving hormonal interven- assigned female at birth (AFAB) who declined FP, 16 gave no reason. tion at our pediatric gender service in Australia. We hypoth- The remaining 33 gave a variety of responses, the proportions of which are esized that the nature of our clinic, which is publicly funded displayed. Of the 19 young people assigned male at birth (AMAB) who declined FP, 9 gave no reason. The remaining 10 gave a variety of responses, the and located alongside a pediatric oncofertility center, might proportions of which are displayed. The item “experimental nature of reduce barriers and increase FP uptake. procedure” refers to the procedure for those in early puberty who have yet to start producing mature gametes, in whom cryopreservation of immature testicular or ovarian tissue harvested via biopsy is offered within a governed Methods | Our statewide service sees transgender individuals pathway that emphasizes that this practice is experimental and requires further who are 18 years or younger. To assess FP use, we conducted technological advances for the tissue to be successfully used for reproductive a retrospective review of all individuals with gender dyspho- purposes. ria who had commenced receiving GnRHa and/or gender- affirming hormones from January 1, 2003, until June 1, 2017. reason was a plan to reassess fertility options when older Information on birth-assigned sex, age, hormonal treatment, (Figure). Conversely, 33 of 53 individuals who were AMAB fertility counseling, and FP use was extracted from the medi- (62%) pursued FP (Table), of whom 22 successfully froze sperm cal record. The Royal Children’s Hospital Human Research Eth- after providing a masturbatory sample (mean [SD] age, 15.6 [1.4] ics Committee approved the study, which included a waiver years). The remaining 11 underwent testicular biopsy (which of informed consent because the study was a secondary use is well suited to those in early puberty), and this group was sig- of medical data. Data were analyzed between August 2017 nificantly younger (mean [SD] age, 13.9 [1.5] years; P = .003). and July 2019. The P value threshold considered significant Five of these 11 individuals were found to have mature sperm, was .05 (2-tailed), and statistical analysis was performed using while the other 6 had germ cells only, all of which were cryo- Prism version 7.0 (GraphPad). preserved. Results | One hundred two patients received fertility counsel- Discussion | Whereas all our patients who were AFAB declined ing from their pediatrician prior to commencing hormones. Of FP, 62% of patients who were AMAB pursued FP, suggesting 53 individuals who were assigned male at birth (AMAB), 23 re- that most transfeminine adolescents have an intrinsic desire ceived counseling prior to taking GnRHa and 30 prior to tak- to preserve their fertility. This result stands in stark contrast ing estrogen, and 14 received additional consultation from an to recent North American studies in which FP rates among the andrologist. Of 49 individuals assigned female at birth (AFAB), AMAB population were 0% to 14%.3-5 Given that our cohort had 3 received counseling prior to taking GnRHa and 46 prior to a similar age and rate of andrology consultation as those in pre- taking testosterone, and 47 received additional consultation vious reports, the most likely explanation is differences in FP from a gynecologist. The mean age at counseling was 15.6 years access. Specifically, patients who were AMAB within our ser- (range, 10.8-18.3 years), with no significant difference be- vice obtain FP in a timely manner (<1 week for masturbatory tween sexes. specimens; <1-2 months for testicular biopsies). This is prob- Among 49 individuals who were AFAB, none attempted ably important, given an unwillingness to delay hormone treat- FP, with 16 stating no reason; among the other 33, the main ment is a common reason for forgoing FP.2,3,5 Furthermore, FP 890 JAMA Pediatrics September 2020 Volume 174, Number 9 (Reprinted) jamapediatrics.com © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Letters Obstetrics & Gynaecology, University of Melbourne, Royal Women’s Hospital Table. Rates of Cryopreservation Between Patients Parkville, Victoria, Australia (Jayasinghe). Assigned Male or Female at Birth Accepted for Publication: October 10, 2020. No. (%) Corresponding Author: Kenneth C. Pang, MBBS(Hons), BMedSc, PhD, Prior to Murdoch Children’s Research Institute, 50 Flemington Rd, Parkville, VIC 3052, commencing Prior to Australia ([email protected]). gonadotropin- commencing releasing hormone estrogen or Published Online: April 13, 2020. doi:10.1001/jamapediatrics.2020.0264 Method of fertility preservation agonistsa testosteronea Author Contributions: Dr Pang and Mr Peri had full access to all of the data in Transgender adolescents assigned 23 (43.4) 30 (56.6) the study and take responsibility for the integrity of the data and the accuracy male at birth (n = 53) of the data analysis. Masturbatory semen collection 7 (30.4) 15 (50.0) Concept and design: Pang, Telfer, Elder. with sperm cryopreservation Acquisition, analysis, or interpretation of data: Pang, Peri, Chung, Grover, Testicular tissue biopsy Jayasinghe. Sperm and testicular tissue 3 (13.0) 2 (6.7)b Drafting of the manuscript: Pang, Chung, Grover. cryopreservation Critical revision of the manuscript for important intellectual content: Pang, Peri, Testicular tissue 4 (17.4) 2 (6.7)b Telfer, Elder, Grover, Jayasinghe. cryopreservation only Statistical analysis: Pang, Peri, Chung. No fertility preservation 9 (39.1) 11 (36.7) Administrative, technical, or material support: Pang, Peri, Chung, Jayasinghe. Supervision: Pang, Telfer, Elder, Grover. Transgender adolescents assigned 3 (6.1) 46 (93.9) female at birth (n = 49) Conflict of Interest Disclosures: Dr Jayasinghe reported grants from University Oocyte retrieval and 00 of Melbourne during the conduct of the study and grants from National Health cryopreservation and Medical Research Council, Victorian Cancer Agency, Royal Children's Ovarian tissue biopsy and 00 Hospital Foundation, University of Melbourne, and Merck outside the cryopreservation submitted work. Dr Pang reported funding from the Royal Children's Hospital No fertility preservation 3 (100) 46 (100) Foundation. No other disclosures were reported. Additional Contributions: The authors would like to thank Charlie Cooper, BA, a It is important to note that gonadotropin-releasing hormone agonists, Murdoch Children's Research Institute, and Timothy Lai, BBiomed, Royal estrogen, and testosterone have differential associations with reproductive Children's Hospital, for conducting literature searches; Debra Gook, BSc, PhD, function. For example, prolonged use of estrogen in patients assigned male at Department of Obstetrics & Gynaecology, University of Melbourne, Royal birth has been associated with impaired spermatogenesis, with the Women's Hospital, and Harold Bourne, BSc, MRepSci, Reproductive Services/ reversibility still unclear. Meanwhile, testosterone administration in patients Melbourne In Vitro Fertilization, Royal Women’s Hospital, for processing and assigned female at birth can similarly impair reproductive function, although analyzing semen samples and testicular biopsies; Michael Nightingale, MB, ChB, this outcome appears reversible. Finally, gonadotropin-releasing hormone Royal Children's Hospital, Murdoch Children’s Research Institute and agonists can be expected to inhibit reproductive development, and although Department of Paediatrics, University of Melbourne, for performing testicular this should also be reversible, most adolescents who undergo pubertal biopsies; Melanie Engel, MD, Royal Children's Hospital, for data extraction; and suppression subsequently proceed to gender-affirming hormones. the staff
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